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Kobayashi M, Une S, Hara H, Honda M. The Impact of Training in Multimodal Communication Skills on Psychotropic Medication Use in Dementia Care. Cureus 2024; 16:e63413. [PMID: 38947140 PMCID: PMC11213625 DOI: 10.7759/cureus.63413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 07/02/2024] Open
Abstract
Aim This study aimed to assess the trends in psychotropic drug prescriptions among elderly residents with dementia following the continuous implementation of multimodal comprehensive care communication skills training for staff in a long-term care facility. Methods This retrospective single-center cross-sectional study utilized the database of an urban public hospital that included a long-term care facility. The data were collected from 2016 to 2020. All 130 staff members at the hospital (52 nurses, 48 professional caregivers, seven rehabilitation staff members, three physicians, and three pharmacists) initiated multimodal comprehensive care communication skills basic training from October 2014 to December 2015, which was followed by continuous monthly training until the end of 2020. Antipsychotic prescription rates for residents aged over 65 years with dementia were measured throughout the study period. Results A total of 506 eligible residents were identified, the median age was 86.0 years (IQR: 81.0-90.0), and 283 (55.9%) residents were females. The prescription rates for psychotropic drugs among residents with dementia decreased significantly (43.5% in 2016, 27.0% in 2020; p=0.01). Notably, the percentage of patients prescribed anxiolytics decreased significantly (from 4.7% to 0.0%), while the percentage of patients receiving antipsychotic drugs, hypnotics, antidepressants, or antiepileptic drugs remained unchanged over time. The prescription rates for antidementia drugs significantly decreased from 15.3% to 4.0%. Conclusion The prescription rates of psychotropic drugs were significantly reduced following multimodal comprehensive care communication skills training for staff at a long-term care facility. The improvement in communication skills among staff at long-term care facilities has a tangible impact on reducing drug use among elderly residents with dementia.
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Affiliation(s)
- Masaki Kobayashi
- Internal Medicine, Unity Hospital, Rochester Regional Health, Rochester, USA
- General Internal Medicine, Division of Geriatric Research, National Hospital Organization Tokyo Medical Center, Tokyo, JPN
| | - Saki Une
- General Internal Medicine, Division of Geriatric Research, National Hospital Organization Tokyo Medical Center, Tokyo, JPN
| | - Hisao Hara
- Internal Medicine, Koriyama Medical Care Hospital, Koriyama, JPN
| | - Miwako Honda
- General Internal Medicine, Division of Geriatric Research, National Hospital Organization Tokyo Medical Center, Tokyo, JPN
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Harnisch M, Barnett ML, Coussens S, Thomas KS, Olfson M, Berhane K, Sacarny A. Physician Antipsychotic Overprescribing Letters and Cognitive, Behavioral, and Physical Health Outcomes Among People With Dementia: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e247604. [PMID: 38662373 PMCID: PMC11046341 DOI: 10.1001/jamanetworkopen.2024.7604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/22/2024] [Indexed: 04/26/2024] Open
Abstract
Importance Antipsychotics, such as quetiapine, are frequently prescribed to people with dementia to address behavioral symptoms but can also cause harm in this population. Objective To determine whether warning letters to high prescribers of quetiapine can successfully reduce its use among patients with dementia and to investigate the impacts on patients' health outcomes. Design, Setting, and Participants This is a secondary analysis of a randomized clinical trial of overprescribing letters that began in April 2015 and included the highest-volume primary care physician (PCP) prescribers of quetiapine in original Medicare. Outcomes of patients with dementia were analyzed in repeated 90-day cross-sections through December 2018. Analyses were conducted from September 2021 to February 2024. Interventions PCPs were randomized to a placebo letter or 3 overprescribing warning letters stating that their prescribing of quetiapine was high and under review by Medicare. Main Outcomes and Measures The primary outcome of this analysis was patients' total quetiapine use in days per 90-day period (the original trial primary outcome was total quetiapine prescribing by study PCPs). Prespecified secondary outcomes included measures of cognitive function and behavioral symptoms from nursing home assessments, indicators of depression from screening questionnaires in assessments and diagnoses in claims, metabolic diagnoses derived from assessments and claims, indicators of use of the hospital and other health care services, and death. Outcomes were analyzed separately for patients living in nursing homes and in the community. Results Of the 5055 study PCPs, 2528 were randomized to the placebo letter, and 2527 were randomized to the 3 warning letters. A total of 84 881 patients with dementia living in nursing homes and 261 288 community-dwelling patients with dementia were attributed to these PCPs. There were 92 874 baseline patients (mean [SD] age, 81.5 [10.5] years; 64 242 female [69.2%]). The intervention reduced quetiapine use among both nursing home patients (adjusted difference, -0.7 days; 95% CI, -1.3 to -0.1 days; P = .02) and community-dwelling patients (adjusted difference, -1.5 days; 95% CI, -1.8 to -1.1 days; P < .001). There were no detected adverse effects on cognitive function (cognitive function scale adjusted difference, 0.01; 95% CI, -0.01 to 0.03; P = .19), behavioral symptoms (agitated or reactive behavior adjusted difference, -0.2%; 95% CI -1.2% to 0.8% percentage points; P = .72), depression, metabolic diagnoses, or more severe outcomes, including hospitalization and death. Conclusions and Relevance This study found that overprescribing warning letters to PCPs safely reduced quetiapine prescribing to their patients with dementia. This intervention and others like it may be useful for future efforts to promote guideline-concordant care. Trial Registration ClinicalTrials.gov Identifier: NCT05172687.
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Affiliation(s)
- Michelle Harnisch
- PhD Economics Programme, Department of Economics, London School of Economics and Political Science, London, United Kingdom
| | - Michael L. Barnett
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Stephen Coussens
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York
| | - Kali S. Thomas
- Center for Equity in Aging, Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Mark Olfson
- Department of Psychiatry, Department of Epidemiology, Columbia University Irving Medical Center, New York, New York
| | - Kiros Berhane
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Adam Sacarny
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York
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Travers JL, Hade EM, Friedman S, Raval A, Hadson K, Falvey JR. Staffing and Antipsychotic Medication Use in Nursing Homes and Neighborhood Deprivation. JAMA Netw Open 2024; 7:e248322. [PMID: 38656575 PMCID: PMC11043897 DOI: 10.1001/jamanetworkopen.2024.8322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/27/2024] [Indexed: 04/26/2024] Open
Abstract
Importance Inappropriate use of antipsychotic medications in nursing homes is a growing public health concern. Residents exposed to higher levels of socioeconomic deprivation in the area around a nursing home may be currently exposed, or have a long history of exposure, to more noise pollution, higher crime rates, and have less opportunities to safely go outside the facility, which may contribute to psychological stress and increased risk of receiving antipsychotic medications inappropriately. However, it is unclear whether neighborhood deprivation is associated with use of inappropriate antipsychotic medications and whether this outcome is different by facility staffing levels. Objective To evaluate whether reported inappropriate antipsychotic medication use differs in severely and less severely deprived neighborhoods, and whether these differences are modified by higher levels of total nurse staffing. Design, Setting, and Participants This was a cross-sectional analysis of a national sample of nursing homes that linked across 3 national large-scale data sets for the year 2019. Analyses were conducted between April and June 2023. Exposure Neighborhood deprivation status (severe vs less severe) and total staffing hours (registered nurse, licensed practical nurse, certified nursing assistant). Main Outcome and Measures This study estimated the association between neighborhood deprivation and the percentage of long-stay residents who received an antipsychotic medication inappropriately in the nursing home at least once in the past week and how this varied by nursing home staffing through generalized estimating equations. Analyses were conducted on the facility level and adjusted for state fixed effects. Results This study included 10 966 nursing homes (1867 [17.0%] in severely deprived neighborhoods and 9099 [83.0%] in less deprived neighborhoods). Unadjusted inappropriate antipsychotic medication use was greater in nursing homes located in severely deprived neighborhoods (mean [SD], 15.9% [10.7%] of residents) than in those in less deprived neighborhoods (mean [SD], 14.2% [8.8%] of residents). In adjusted models, inappropriate antipsychotic medication use was higher in severely deprived neighborhoods vs less deprived neighborhoods (19.2% vs 17.1%; adjusted mean difference, 2.0 [95% CI, 0.35 to 3.71] percentage points) in nursing homes that fell below critical levels of staffing (less than 3 hours of nurse staffing per resident-day). Conclusions and Relevance These findings suggest that levels of staffing modify disparities seen in inappropriate antipsychotic medication use among nursing homes located in severely deprived neighborhoods compared with nursing homes in less deprived neighborhoods. These findings may have important implications for improving staffing in more severely deprived neighborhoods.
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Affiliation(s)
| | - Erinn M. Hade
- New York University Grossman School of Medicine, Department of Population Health, New York
| | - Steven Friedman
- New York University Grossman School of Medicine, Department of Population Health, New York
| | - Aasha Raval
- New York University Rory Meyers College of Nursing, New York
| | - Kimberly Hadson
- New York University Rory Meyers College of Nursing, New York
| | - Jason R. Falvey
- University of Maryland School of Medicine, Department of Physical Therapy and Rehabilitation Science, Department of Epidemiology and Public Health, Baltimore
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Zhang X, Guan C, He J, Wang J. Barriers and facilitators to dementia care in long-term care facilities: protocol for a qualitative systematic review and meta-synthesis. BMJ Open 2023; 13:e076058. [PMID: 37914310 PMCID: PMC10626821 DOI: 10.1136/bmjopen-2023-076058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/10/2023] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Long-term care needs for people with dementia are predicted to increase due to increased life expectancy and dementia diagnoses. Most published meta- syntheses of dementia care focus on hospitals or home settings. When focusing on long-term care facilities, most reviews about dementia care only focus on a single outcome, such as feeding, behavioural symptoms management, palliative care and others, which is limited. The present study aims to synthesise qualitative data and examine barriers and facilitators to caring for people with dementia in long-term care facilities. METHODS AND ANALYSIS This is the protocol for our systematic review and meta-synthesis, which describes the design of this study, and we plan to complete the study from October 2023 to November 2024. The systematic review and meta-synthesis will follow the Joanna Briggs Institute (JBI) guidance for systematic reviews of qualitative evidence. Nine databases (five English and four Chinese) were searched, including Embase, Web of Science, Medline, CINAHL, PsycINFO and Wan Fang Data, China National Knowledge Infrastructure, VIP and Chinese Biomedical Medicine, from inception to August 2023. Qualitative and mixed-approach research about barriers and facilitators to caring for people with dementia in long-term care facilities, which are reported in English or Chinese, will be included. Covidence software will help with study selection, assessment and data extraction. The JBI Critical Appraisal Checklist for Qualitative Research (2020) will be used for included studies' quality assessment. Data extraction will be based on the JBI Qualitative Assessment and Review Instrument Data Extraction Tool for Qualitative Research. The JBI aggregation approach will be used to synthesise data. We will use the JBI ConQual tool to assess the credibility and dependability of each synthesised finding to establish confidence in the synthesised findings. All review steps will be managed by two reviewers independently, and disparities will be discussed. If consensus cannot reach a resolution, a third reviewer will be consulted. ETHICS AND DISSEMINATION The present study is a secondary analysis of published qualitative data. So ethical approval is not required. The findings may be disseminated through peer-reviewed publications, conference papers or elsewhere. PROSPERO REGISTRATION NUMBER The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) in May 2022, and the registration number is CRD42022326178.
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Affiliation(s)
- Xi Zhang
- Faculty of Nursing, Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Chengguo Guan
- School of Nursing, The Open University of Shaanxi, Xi'an, Shaanxi, China
| | - Jinjie He
- School of Economics and Management, Xi'an University, Xi'an, Shaanxi, China
| | - Jing Wang
- Faculty of Nursing, Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Willems J, Passos VL, Hamers JPH, Bleijlevens MHC. Professional caregivers' perceived barriers hindering the prevention and reduction of involuntary treatment among older persons receiving long-term care: A mixed methods study. J Clin Nurs 2023; 32:7175-7192. [PMID: 37458214 DOI: 10.1111/jocn.16796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 03/14/2023] [Accepted: 05/30/2023] [Indexed: 07/27/2023]
Abstract
AIMS To gain insights into the barriers towards the prevention and/or reduction of involuntary treatment in long-term geriatric care. DESIGN Mixed methods. BACKGROUND Measures to which a person resists and/or does not provide consent for are defined as involuntary treatment. The use of involuntary treatment violates the autonomy of (older) persons and causes more harm than benefit. Moreover, it contradicts the values of person-centred care. Nevertheless, its use among people living with dementia (PLWD) is still common practice. METHODS We conducted a cross-sectional, mixed methods study, including an online survey for professional caregivers and a semistructured focus group interview with professional caregivers. RESULTS A total of 218 participants completed the questionnaire. The percentage of participants who perceived barriers in one of the 22 survey items ranged from 15% to 42%. Lack of time, the experienced need to use involuntary treatment, uncertainty about responsibilities of stakeholders and a lack of knowledge on methods to prevent and/or reduce the use of involuntary treatment were most seen as barriers. Nursing staff perceived a lack of time hindering them in the prevention or reduction of involuntary treatment more often than other professional caregivers. Working in home care and having no former experience with involuntary treatment usage increased perceived barriers. Participants of the focus group interview confirmed these findings and added that professional caregivers in general lack awareness on the concept of involuntary treatment. CONCLUSIONS One out of four professional caregivers experiences barriers hindering prevention and/or reduction of involuntary treatment. More research is needed to gain a better understanding of how professional caregivers can be supported to remove barriers and, consequently, prevent and/or reduce the use of involuntary treatment. RELEVANCE TO CLINICAL PRACTICE Professional caregivers experience many barriers towards the prevention and reduction of involuntary treatment. Future initiatives should aim to remove the perceived barriers.
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Affiliation(s)
- Jules Willems
- Faculty of Health, Medicine and Lifesciences, CAPHRI Care and Public Health Research Institute, Living Lab in Ageing and Long-term Care, Maastricht University, Maastricht, The Netherlands
| | - Valéria Lima Passos
- Faculty of Health, Medicine and Lifesciences, Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Jan P H Hamers
- Faculty of Health, Medicine and Lifesciences, CAPHRI Care and Public Health Research Institute, Living Lab in Ageing and Long-term Care, Maastricht University, Maastricht, The Netherlands
| | - Michel H C Bleijlevens
- Faculty of Health, Medicine and Lifesciences, CAPHRI Care and Public Health Research Institute, Living Lab in Ageing and Long-term Care, Maastricht University, Maastricht, The Netherlands
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Raza A, Piekarz H, Jawad S, Langran T, Donyai P. A systematic review of quantitative studies exploring staff views on antipsychotic use in residents with dementia in care homes. Int J Clin Pharm 2023; 45:1050-1061. [PMID: 37773304 PMCID: PMC10600045 DOI: 10.1007/s11096-023-01645-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/26/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Despite significant warnings of adverse effects, antipsychotics continue to be prescribed for managing the behavioural and psychological symptoms of dementia (BPSD) in care homes. Information provided by staff working within care homes is a factor that can influence prescribing decisions in residents with BPSD. AIM The review aimed to capture care home staff views towards antipsychotics for residents with BPSD and separately analyse tools utilized in the studies, mapping them onto the theory of planned behaviour (TPB). METHOD A comprehensive literature search published in ten databases was conducted between May and July 2020 and updated in July 2021. Studies published in full with no date restriction were included and quality assessed using CROSS checklist. A thematic framework approach was applied to extract data and study tools which were then mapped onto the TPB. RESULTS Fourteen studies (2059 participants) were included. Findings identified four overarching themes: attitudes toward antipsychotics (e.g. antipsychotics as an appropriate strategy and effectiveness); barriers to deprescribing (e.g. lower staff education, lack of resources and time, poor medication reviews); measures implemented (e.g. nonpharmacological interventions, medication reviews); and perceived needs of staff (e.g. need for training, financial or clinical support). Identified tools addressed seven but not all components of TPB namely, behavioural, normative and control beliefs, attitude, perceived behavioural control, intention and behaviour. CONCLUSION The positive attitudes toward antipsychotics, the identified barriers to deprescribing and the existing tools not addressing all components of the TPB provide the impetus for further research.
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Affiliation(s)
- Amna Raza
- Reading School of Pharmacy, University of Reading, Reading, UK.
| | - Hannah Piekarz
- Reading School of Pharmacy, University of Reading, Reading, UK
| | - Sundus Jawad
- NHS Frimley, King Edward VII Hospital, Windsor, UK
| | - Tim Langran
- NHS Frimley, King Edward VII Hospital, Windsor, UK
| | - Parastou Donyai
- Department of Pharmacy and Forensic Science, King's College London, London, UK
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Lühnen J, Richter T, Calo S, Meyer G, Köpke S, Möhler R. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev 2023; 8:CD008634. [PMID: 37650479 PMCID: PMC10471006 DOI: 10.1002/14651858.cd008634.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Antipsychotic medications are regularly prescribed in care home residents for the management of behavioural and psychological symptoms of dementia (BPSD) despite questionable efficacy, important adverse effects, and available non-pharmacological interventions. Prescription rates are related to organisational factors, staff training and job satisfaction, patient characteristics, and specific interventions. Psychosocial intervention programmes aimed at reducing the prescription of antipsychotic drugs are available. These programmes may target care home residents (e.g. improving communication and interpersonal relationships) or target staff (e.g. by providing skills for caring for people with BPSD). Therefore, this review aimed to assess the effectiveness of these interventions, updating our earlier review published in 2012. OBJECTIVES To evaluate the benefits and harms of psychosocial interventions to reduce antipsychotic medication use in care home residents compared to regular care, optimised regular care, or a different psychosocial intervention. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 14 July 2022. SELECTION CRITERIA We included individual or cluster-randomised controlled trials comparing a psychosocial intervention aimed primarily at reducing the use of antipsychotic medication with regular care, optimised regular care, or a different psychosocial intervention. Psychosocial interventions were defined as non-pharmacological intervention with psychosocial components. We excluded medication withdrawal or substitution interventions, interventions without direct interpersonal contact and communication, and interventions solely addressing policy changes or structural interventions. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Critical appraisal of studies addressed risks of selection, performance, attrition and detection bias, as well as criteria related to cluster randomisation. We retrieved data on the complex interventions on the basis of the TIDieR (Template for Intervention Description and Replication) checklist. Our primary outcomes were 1. use of regularly prescribed antipsychotic medication and 2. ADVERSE EVENTS Our secondary outcomes were 3. mortality; 4. BPSD; 5. quality of life; 6. prescribing of regularly psychotropic medication; 7. regimen of regularly prescribed antipsychotic medication; 8. antipsychotic medication administered 'as needed'; 9. physical restraints; 10. cognitive status; 11. depression; 12. activities of daily living; and 13. COSTS We used GRADE to assess certainty of evidence. MAIN RESULTS We included five cluster-randomised controlled studies (120 clusters, 8342 participants). We found pronounced clinical heterogeneity and therefore decided to present study results narratively. All studies investigated complex interventions comprising, among other components, educational approaches. Because of the heterogeneity of the results, including the direction of effects, we are uncertain about the effects of psychosocial interventions on the prescription of antipsychotic medication. One study investigating an educational intervention for care home staff assessed the use of antipsychotic medication in days of use per 100 resident-days, and found this to be lower in the intervention group (mean difference 6.30 days, 95% confidence interval (CI) 6.05 to 6.66; 1152 participants). The other four studies reported the proportion of participants with a regular antipsychotic prescription. Of two studies implementing an intervention to promote person-centred care, one found a difference in favour of the intervention group (between-group difference 19.1%, 95% CI 0.5% to 37.7%; 338 participants), while the other found a difference in favour of the control group (between-group difference 11.4%, 95% CI 0.9% to 21.9%; 862 participants). One study investigating an educational programme described as "academic detailing" found no difference between groups (odds ratio 1.06, 95% CI 0.93 to 1.20; 5363 participants). The fifth study used a factorial design to compare different combinations of interventions to supplement person-centred care. Results showed a positive effect of medication review, and no clear effect of social interaction or exercise. We considered that, overall, the evidence about this outcome was of low certainty. We found high-certainty evidence that psychosocial interventions intended primarily to reduce antipsychotic use resulted in little to no difference in the number of falls, non-elective hospitalisations, or unplanned emergency department visits. Psychosocial interventions intended primarily to reduce antipsychotic use also resulted in little to no difference in quality of life (moderate-certainty evidence), and BPSD, regular prescribing of psychotropic medication, use of physical restraints, depression, or activities of daily living (all low-certainty evidence). We also found low-certainty evidence that, in the context of these interventions, social interaction and medication review may reduce mortality, but exercise does not. AUTHORS' CONCLUSIONS All included interventions were complex and the components of the interventions differed considerably between studies. Interventions and intervention components were mostly not described in sufficient detail. Two studies found evidence that the complex psychosocial interventions may reduce antipsychotic medication use. In addition, one study showed that medication review might have some impact on antipsychotic prescribing rates. There were no important adverse events. Overall, the available evidence does not allow for clear generalisable recommendations.
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Affiliation(s)
- Julia Lühnen
- Institute of Health and Nursing Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Institute of Clinical Nursing Science, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Tanja Richter
- Unit of Health Sciences and Education, University of Hamburg, Hamburg, Germany
| | - Stella Calo
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Gabriele Meyer
- Institute of Health and Nursing Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Sascha Köpke
- Unit of Health Sciences and Education, University of Hamburg, Hamburg, Germany
- Institute of Nursing Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ralph Möhler
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
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Yoon JM, Trinkoff AM, Kim M, Kim E. State-level nursing home in-service dementia training requirements and inappropriate psychotropic medication use. Geriatr Nurs 2023; 51:209-214. [PMID: 37011493 DOI: 10.1016/j.gerinurse.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/07/2023] [Accepted: 03/07/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Although non-pharmacological interventions, which are staff intensive, are recommended for behavioral symptoms of dementia, psychotropics are often prescribed in nursing homes (NHs), with insufficient nurse staffing levels and dementia care training. Since 2017, deficiency citations can be assigned for inappropriate psychotropics use (F-758 tag). Some states require in-service dementia training above federal minimums, but it is unknown whether extra dementia training requirements were related to fewer F-758 citations for residents with dementia and whether nurse staffing influenced the relationship between receiving F-758 citations and having additional state-level dementia training requirements. PURPOSE To relate F-758 citation occurrence to extra in-service dementia training regulations and to explore how the relationships are affected by nurse staffing levels. METHOD Generalized linear mixed models were used to examine F-758 citation occurrence in relation to state-level in-service dementia training regulations. Stratification was also conducted to compare the effects in NHs with low versus high nurse staffing. FINDINGS Requiring in-service dementia training with extra hours was inversely related to receiving F-758 tags. That relationship was also noted in NHs with lower registered nurse and certified nurse assistant staffing. DISCUSSION In-service dementia training may be helpful in reducing inappropriate psychotropics use, particularly in facilities with lower nurse staffing.
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Affiliation(s)
- Jung Min Yoon
- Ewha Womans University, College of Nursing, Seoul, South Korea.
| | | | - Miyoung Kim
- Ewha Womans University, College of Nursing, Seoul, South Korea.
| | - Eunjin Kim
- Ewha Womans University, College of Nursing, Seoul, South Korea.
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Timmons S, Bracken-Scally M, Chakraborty S, Gallagher P, Hamilton V, Begley E, O'Shea E. Psychotropic Medication Prescribing to Patients with Dementia Admitted to Acute Hospitals in Ireland. Drugs Aging 2023; 40:461-472. [PMID: 36995582 DOI: 10.1007/s40266-023-01020-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Psychotropic medications are commonly prescribed to people with dementia (PwD) for non-cognitive symptoms of dementia (NCSD), but have significant risks. A national audit was performed in acute hospitals in the Republic of Ireland (ROI) to establish baseline practice prior to the launch and implementation of a National Clinical Guideline on the appropriate prescribing of psychotropic medications for NCSD. The objective of this study was to analyse psychotropic prescribing patterns and compare these with international data and with existing (limited) data from a previous audit round. METHODS The pooled anonymous dataset from the second round of the Irish National Audit of Dementia Care (INAD-2) was analysed. The audit had collected retrospective data from 30 random healthcare records from each of 30 acute hospitals in 2019. Inclusion criteria were a clinical diagnosis of dementia of any type, hospital stay of 72 hours or more, and discharge or death within the audit period. Most hospitals (87%) self-audited their healthcare records, but a random sample of six healthcare records (20%) from each hospital were re-audited by a highly trained healthcare auditor. The audit tool was based on a tool used in the England and Wales National Audit of Dementia audit rounds (Royal College of Psychiatrists), adapted to the Irish healthcare setting and national priorities. RESULTS In total, 893 cases were included, as one hospital could not retrieve 30 cases even within a more prolonged audit period. The sample comprised 55% females and 45% males; the median age was 84 years (interquartile range 79-88 years) and the majority (89.6%) were >75 years of age. Only 52% of healthcare records specified the type of dementia; within these, the most common diagnosis was Alzheimer's disease (45%). Most PwD (83%) were receiving psychotropic medication on admission; 40% were prescribed new or increased psychotropic medication during admission, mainly for medical indications, including end-of-life care and delirium. Anticonvulsants or cognitive enhancers were rarely prescribed for NCSD in hospital. However, new/increased antipsychotic medication was prescribed for NCSD in 11.8-17.6% of the total cohort, while 4.5-7.7% were prescribed a benzodiazepine for anxiety or NCSD. Overall, there was poor documentation of risk/benefit, or of discussion with the patient/family, and apparently inadequate review for efficacy and tolerability. Concurrently, acetylcholinesterase inhibitors appeared to be underused for cognitive impairment in the community. CONCLUSION This audit provides baseline data on psychotropic medication prescription for NCSD in Irish hospitals prior to a specific Irish guideline on this topic. Reflecting this, most PwD were receiving psychotropic medications on admission, and many were prescribed new/increased psychotropic medication in hospital, often without evidence of appropriate decision making and prescribing processes.
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Affiliation(s)
- Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | | | - Shelly Chakraborty
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | | | | | - Emer Begley
- National Dementia Office, Health Service Executive, Tullamore, Ireland
| | - Emma O'Shea
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland.
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Timmons S, Fox S. Palliative care for people with dementia. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:81-105. [PMID: 36599517 DOI: 10.1016/b978-0-12-824535-4.00013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Dementia is the most common neurologic disease, affecting approximately 55 million people worldwide. Dementia is a terminal illness, although not always recognized as such. This chapter discusses the key issues in providing palliative care for people with living with dementia and their families. Common palliative care needs and symptoms are presented, including psychosocial, physical, emotional, and spiritual, and the need to actively anticipate and seek symptoms according to the dementia type and stage is emphasized. Families are hugely impacted by a dementia diagnosis, and throughout this chapter, they are considered in the unit of care, and also as a member of the care team. Multiple challenges particular to dementia palliative care are highlighted throughout, such as the lack of timely dementia diagnoses, difficulty with symptom prognostication, the person's inability to verbally express their symptoms and care preferences, and a low threshold for medication side effects. Finally, service models for dementia palliative care in community, residential, and acute hospital settings are discussed, along with the evidence for each. Overall, this chapter reinforces that the individual needs of the person living with dementia and their family must be considered to provide person-centered and comprehensive palliative care, enabling them to live well until death.
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Affiliation(s)
- Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland; Department of Geriatric Medicine, Mercy University Hospital & St. Finbarr's Hospital, Cork, Ireland.
| | - Siobhan Fox
- Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
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Walsh KA, Byrne S, O'Riordan A, McSharry J, Browne J, Irving K, Hurley E, Timmons S. Rationalising Antipsychotic Prescribing in Dementia (RAPID) complex intervention: A mixed-methods feasibility intervention study. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 8:100190. [PMID: 36277309 PMCID: PMC9579044 DOI: 10.1016/j.rcsop.2022.100190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/29/2022] [Accepted: 10/08/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND To help address the issue of inappropriate antipsychotic prescribing to nursing home residents with dementia, the 'Rationalising Antipsychotic Prescribing in Dementia' (RAPID) complex intervention was developed, comprising staff education and training, academic detailing and a novel resident assessment tool. OBJECTIVES The primary objective was to assess the feasibility and acceptability of the RAPID complex intervention in a nursing home setting. The secondary objective was to describe associated trends in psychotropic prescribing, falls, and behavioural symptoms. METHODS A mixed-methods feasibility intervention study in one large nursing home in Ireland was undertaken between 07/2017 and 01/2018. Focus groups and semi-structured interviews were conducted with nursing home staff and GPs at the end of the 3-month follow up period to assess participants' experience of the intervention. Quantitative measurements included pre- and post-course evaluation and psychotropic prescribing rates. RESULTS Sixteen nursing home staff members attended the two education and training days (21% attendance rate), and four GPs participated in the academic detailing sessions (100% attendance rate). Participants of the focus groups and interviews (n = 18) found the education and training beneficial for their work and expressed a desire to continue educating new staff after the study's completion. However, there was limited usage of the resident assessment tool. Participants also offered recommendations to enhance the intervention.The proportion of dementia residents prescribed at least one regular antipsychotic was stable over the 3-months pre-intervention at 45% (n = 18), and at baseline at 44% (n = 19) but decreased slightly to 36% (n = 14) at 3-months post-intervention. At the same time the absolute number of 'PRN' psychotropics administered monthly to dementia residents decreased substantially from 90 at baseline to 69 at 3-months post-intervention. CONCLUSION The RAPID complex intervention was broadly feasible to conduct and may be acceptable to stakeholders. However, before it can be evaluated in larger scale studies, certain protocol modifications and further exploratory work are required to improve implementation.
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Key Words
- ABC, Antecedent-Behaviour-Consequence
- Antipsychotics
- BCW, behaviour change wheel
- BPSD, behavioural and psychological symptoms of dementia
- CNM, clinical nurse manager
- COS, core outcome set
- CPZ, chlorpromazine
- Dementia
- Feasibility study
- GP, general practitioner
- GRAMMS, Good Reporting of A Mixed-Methods Study
- HCA, healthcare assistant
- Inappropriate prescribing
- Long term care facility
- MRC, Medical Research Council
- NIHR, National Institute for Health Research
- NPI-NH, neuropsychiatric inventory - nursing home version
- Nursing home
- OD, occupational disruptiveness
- PINCH-ME, Pain, Infection, Nutrition, Constipation, Hydration, Medication and Environment
- PRN, pro re nata
- QUM-D, quality use of medicines in dementia
- RAPID, Rationalising Antipsychotic Prescribing in Dementia
- WHO-ATC, World Health Organization Anatomical Therapeutic Chemical
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Affiliation(s)
- Kieran A. Walsh
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
- School of Public Health, University College Cork, Cork, Ireland
- Corresponding author at: Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork T12YN60, Ireland.
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - Alex O'Riordan
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - Jenny McSharry
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland, Galway, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Kate Irving
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland
| | - Eimir Hurley
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
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Wiggin DA, Timmons S, Rukundo A, Walsh KA. Improving the appropriateness of psychotropic prescribing for nursing home residents with dementia: an overview of reviews. Aging Ment Health 2022; 26:1087-1094. [PMID: 33982608 DOI: 10.1080/13607863.2021.1922601] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Psychotropic medications are commonly inappropriately prescribed for people with dementia (PwD) residing in nursing homes. This population is often multi-morbid, receiving multiple medications and therefore at an increased risk of mortality. This overview aimed to collate all synthesised quantitative, qualitative, and mixed-method evidence pertaining to the effectiveness of interventions aimed at reducing inappropriate psychotropic prescribing for nursing home residents with dementia; the perceived barriers and facilitators to the implementation of these interventions; and the attitudes and experiences of stakeholders toward prescribing. Method: An overview of reviews was conducted (PROSPERO protocol registration CRD42020187288). Five databases were systematically searched from January 2010 through June 2020, supplemented by grey literature searching. Reviews presenting evidence pertaining to either randomised controlled trials (RCT) aiming to reduce inappropriate prescribing or qualitative/mixed method studies of stakeholder views, were included. RESULTS Of 273 records identified, 11 systematic reviews were included. The quality of reviews ranged from critically low to moderate. There was mixed evidence for the use of education-only interventions. Multicomponent interventions (typically staff education combined with organisational and structural components), medication review, and interventions aimed at cultural change were evidenced as effective compared to care as usual. Stakeholders cited the importance of multidisciplinary collaboration and targeting organisational climate in changing psychotropic prescribing behaviours. CONCLUSIONS The inappropriate use of psychotropic medications in nursing homes for PwD is a complex issue with many contextual factors. The evidence suggests a comprehensive approach, targeting organisational climate and multidisciplinary collaboration, along with staff education and training, may be an effective strategy.
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Affiliation(s)
- Daisy A Wiggin
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Aphie Rukundo
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Kieran A Walsh
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
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O’Donnell E, Holland C, Swarbrick C. Strategies used by care home staff to manage behaviour that challenges in dementia: a systematic review of qualitative studies. Int J Nurs Stud 2022; 133:104260. [DOI: 10.1016/j.ijnurstu.2022.104260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 02/14/2022] [Accepted: 04/17/2022] [Indexed: 11/24/2022]
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Harper AE, Terhorst L, Moscirella M, Turner RL, Piersol CV, Leland NE. The experiences, priorities, and perceptions of informal caregivers of people with dementia in nursing homes: A scoping review. DEMENTIA 2021; 20:2746-2765. [PMID: 33899537 DOI: 10.1177/14713012211012606] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Person-centered care has been shown to increase desired outcomes for people with dementia, yet informal caregivers' dissatisfaction with care is often reported. For those living in a nursing home, informal caregivers are uniquely situated to provide key insights into the individual's care. However, little is known of the informal caregivers' perspective, which hinders efforts to improve their satisfaction with person-centered nursing home care. Thus, we examined the comprehensive experiences, priorities, and perceptions of informal caregivers of nursing home residents with dementia. METHODS In collaboration with stakeholders, a scoping review of Medline (Ovid), EMBASE.com, CINAHL (EBSCO), the Cochrane Library (Wiley), and PsycINFO (Ovid) databases from January 2000 to July 2020 was conducted. Data were extracted reflecting the experiences, priorities, and preferences of caregivers of people with dementia residing in nursing homes. RESULTS We identified 114 articles that revealed nine themes: (1) communication, (2) transition to nursing home, (3) quality of care, (4) quality of life, (5) informal caregiver role, (6) knowledge of dementia, (7) end-of-life preferences, (8) medication use to manage neuropsychiatric behaviors, and (9) finances. CONCLUSION Informal caregivers described aspects of care that led to both positive and negative experiences with and perceptions of nursing home care. The shortcomings in communication were discussed most frequently, indicating a high priority area. While researchers define the identified themes individually, informal caregivers perceive them to be interwoven as they relate to person-centered care delivery. Although we did not assess the quality of included articles, by identifying themes relevant to caregivers' perspectives of nursing home care, our findings may help to inform efforts to optimize caregivers' satisfaction with nursing home care for residents with dementia.
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Affiliation(s)
- Alexandra E Harper
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Lauren Terhorst
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Marybeth Moscirella
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Rose L Turner
- Health Sciences Library System, 499478University of Pittsburgh, Pittsburgh, PA, USA
| | - Catherine V Piersol
- Department of Occupational Therapy, Jefferson College of Rehabilitation Sciences, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Natalie E Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, 6614University of Pittsburgh, Pittsburgh, PA, USA
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Walsh KA, Timmons S, Byrne S, Browne J, Mc Sharry J. Identifying behavior change techniques for inclusion in a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia. Transl Behav Med 2021; 11:470-483. [PMID: 32589204 DOI: 10.1093/tbm/ibaa053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Nursing home residents with dementia are commonly prescribed antipsychotics despite the associated increased risk of harms. Interventions to optimize prescribing practice have been found to be effective in the short term, but there is a lack of evidence to support sustainability of effects, along with a lack of theory, public involvement, and transparency in the intervention development process. Using theory has been advocated as a means of improving intervention sustainability. The aim of this study was, therefore, to identify behavior change techniques (BCTs) for inclusion in a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia. A comprehensive approach to identifying a long list of all potential BCTs from three different sources was undertaken. The most appropriate BCTs were then selected through a two-round Delphi consensus survey with a broad range of experts (n = 18 panelists). Advisory groups of people with dementia, family carers, and professional stakeholders provided feedback on the final BCTs included. After two Delphi survey rounds, agreement was reached on 22 BCTs. Further refinement of the selected BCTs based on advisory group and panelists' feedback, along with use of the APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side effects/safety, and Equity) resulted in a final list of 16 BCTs. The next step in intervention development will be to identify the most appropriate mode of delivery of the 16 BCTs identified for inclusion. The study provides a case example of a systematic approach to incorporating evidence with stakeholder views in the identification of appropriate BCTs.
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Affiliation(s)
- Kieran A Walsh
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland.,Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Jenny Mc Sharry
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland Galway, Galway, Ireland
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Moth AE, Hølmkjær P, Holm A, Rozing MP, Overbeck G. What Makes Deprescription of Psychotropic Drugs in Nursing Home Residents with Dementia so Challenging? A Qualitative Systematic Review of Barriers and Facilitators. Drugs Aging 2021; 38:671-685. [PMID: 34231182 PMCID: PMC8342345 DOI: 10.1007/s40266-021-00875-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 12/03/2022]
Abstract
Background Behavioral and psychological symptoms of dementia are frequently experienced in the nursing home setting and place a substantial burden on patients, relatives, and nursing home staff. Despite guidelines recommending non-pharmacological treatments, psychotropic drugs are often prescribed to address these symptoms. This is the case despite their effects being limited, and there being a risk of side effects and adverse events for the patient. Several studies have aimed to reduce the use of psychotropic drugs, with varying results. The reasons behind these variations are not well understood. Objectives The objective of this systematic review was to investigate which factors nursing home general practitioners and nursing home staff experience as barriers or facilitators when attempting to deprescribe psychotropic drugs in nursing home residents. Methods We searched PubMed, EMBASE, psycINFO, Web of Science, and CINAHL between April and September 2020. An inductive method using thematic analysis of the qualitative findings was applied for the derivation of themes. Quantitative studies were included but described descriptively and separately. Results Of 8204 unique records, 14 studies were included in the review. Of these, nine were interview or focus group studies and five were survey studies. Thematic analysis resulted in five major themes identified as either facilitators or barriers or both: (1) ‘Operationality and routines’; (2) ‘Lack of resources and qualifications’; (3) ‘Patient-related outcomes’, which points to a strong belief in negative patient-related outcomes of discontinuation and a downplay of side effects of the medication; (4) ‘Policies’, including support and buy-in from nursing home leadership; and (5) ‘Collaboration’ between physicians and nursing home staff. Themes 1 and 4 consist of facilitators. Theme 2 consists of barriers. Theme 3 and 5 consist of both facilitators and barriers. Evaluation of closed-ended questions from the surveys supported the findings. Conclusions Deprescribing psychotropic drugs used for behavioral and psychological symptoms of dementia in nursing home residents is challenging. Resources need to be in place for deprescribing, as well as there being a focus on the positive patient-related outcomes of doing so. Managerial support, staff routines, and interprofessional collaboration are some factors facilitating the process, in addition to there being routines and systematic procedures in place allowing for operationality and a common understanding. Addressing these barriers and facilitators is necessary to ensure that deprescribing can be understood as meaningful and pursued among healthcare professionals in the nursing home setting. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-021-00875-1.
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Affiliation(s)
| | - Pernille Hølmkjær
- Department of General Practice, University of Copenhagen, Copenhagen, Denmark.
| | - Anne Holm
- Department of General Practice, University of Copenhagen, Copenhagen, Denmark
| | | | - Gritt Overbeck
- Department of General Practice, University of Copenhagen, Copenhagen, Denmark
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Spinewine A, Evrard P, Hughes C. Interventions to optimize medication use in nursing homes: a narrative review. Eur Geriatr Med 2021; 12:551-567. [PMID: 33751478 PMCID: PMC8149362 DOI: 10.1007/s41999-021-00477-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/25/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE Polypharmacy, medication errors and adverse drug events are frequent among nursing home residents. Errors can occur at any step of the medication use process. We aimed to review interventions aiming at optimization of any step of medication use in nursing homes. METHODS We narratively reviewed quantitative as well as qualitative studies, observational and experimental studies that described interventions, their effects as well as barriers and enablers to implementation. We prioritized recent studies with relevant findings for the European setting. RESULTS Many interventions led to improvements in medication use. However, because of outcome heterogeneity, comparison between interventions was difficult. Prescribing was the most studied aspect of medication use. At the micro-level, medication review, multidisciplinary work, and more recently, patient-centered care components dominated. At the macro-level, guidelines and legislation, mainly for specific medication classes (e.g., antipsychotics) were employed. Utilization of technology also helped improve medication administration. Several barriers and enablers were reported, at individual, organizational, and system levels. CONCLUSION Overall, existing interventions are effective in optimizing medication use. However there is a need for further European well-designed and large-scale evaluations of under-researched intervention components (e.g., health information technology, patient-centered approaches), specific medication classes (e.g., antithrombotic agents), and interventions targeting medication use aspects other than prescribing (e.g., monitoring). Further development and uptake of core outcome sets is required. Finally, qualitative studies on barriers and enablers for intervention implementation would enable theory-driven intervention design.
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Affiliation(s)
- Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier 72/B1.72.02, Woluwe-Saint-Lambert, 1200, Brussels, Belgium.
- Pharmacy Department, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium.
| | - Perrine Evrard
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier 72/B1.72.02, Woluwe-Saint-Lambert, 1200, Brussels, Belgium
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Walsh KA, Byrne S, McSharry J, Browne J, Irving K, Hurley E, Rochford-Brennan H, Geoghegan C, Presseau J, Timmons S. Developing a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia. HRB Open Res 2021; 4:23. [PMID: 34136749 PMCID: PMC8185579 DOI: 10.12688/hrbopenres.13228.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 01/23/2023] Open
Abstract
Background: Antipsychotics are commonly prescribed to people living with dementia in nursing home settings, despite strong guideline recommendations against their use except in limited circumstances. We aimed to transparently describe the development process for a complex intervention targeting appropriate requesting and prescribing of antipsychotics to nursing home residents with dementia in Ireland, by nurses and general practitioners (GPs) respectively. Methods: We report the development process for the ‘Rationalising Antipsychotic Prescribing in Dementia’ (RAPID) complex intervention, in accordance with the ‘Guidance for reporting intervention development studies in health research’ (GUIDED) checklist. The UK Medical Research Council framework for developing and evaluating complex interventions guided our overall approach, incorporating evidence and theory into the intervention development process. To unpack the intervention development process in greater detail, we followed the Behaviour Change Wheel approach. Guided by our stakeholders, we conducted three sequential studies (systematic review and qualitative evidence synthesis, primary qualitative study and expert consensus study), to inform the intervention development. Results: The RAPID complex intervention was developed in collaboration with a broad range of stakeholders, including people living with dementia and family carers, between 2015 and 2017. The finalised RAPID complex intervention was comprised of the following three components; 1) Education and training sessions with nursing home staff; 2) Academic detailing with GPs; 3) Introduction of an assessment tool to the nursing home. Conclusions: This paper describes the steps used by the researchers to develop a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia in Ireland, according to the GUIDED checklist. We found that the GUIDED checklist provided a useful way of reporting all elements in a cohesive manner and complemented the other tools and frameworks used. Transparency in the intervention development processes can help in the translation of evidence into practice.
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Affiliation(s)
- Kieran A Walsh
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, T12XH60, Ireland.,Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, T12YN60, Ireland.,School of Public Health, University College Cork, Cork, T12K8AF, Ireland
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, T12YN60, Ireland
| | - Jenny McSharry
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland, Galway, Galway, H91TK33, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, T12K8AF, Ireland
| | - Kate Irving
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland
| | - Eimir Hurley
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Helen Rochford-Brennan
- Expert by Experience, N/A, N/A, Ireland.,Irish Dementia Working Group, The Alzheimer Society of Ireland, Dublin, Ireland
| | | | - Justin Presseau
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, K1H 8L6, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, K1G 5Z3, Canada
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, T12XH60, Ireland
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Ma D, Zhao Y, Wan Z, Sun D, Li H, Xie Z, Sun J. Nurses' attitudes and views on the application of antipsychotics in patients with dementia: A systematic review of qualitative studies. Geriatr Nurs 2020; 41:669-676. [DOI: 10.1016/j.gerinurse.2019.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/19/2019] [Accepted: 10/23/2019] [Indexed: 11/25/2022]
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Rosenthal M, Poling J, Wec A, Connolly E, Angell B, Crystal S. "Medication Is Just One Piece of the Whole Puzzle": How Nursing Homes Change Their Use of Antipsychotic Medications. J Appl Gerontol 2020; 41:62-72. [PMID: 32996374 DOI: 10.1177/0733464820958919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Antipsychotic medication use for nursing home residents with dementia poses major patient safety challenges. This article investigates health professionals' experiences with decision-making during changes under the National Partnership to Improve Dementia Care in Nursing Homes (National Partnership) and its companion state coalitions. These programs were introduced in 2012 to encourage reductions in antipsychotic use and increased use of nonpharmacological treatments for dementia. Interviews with 40 nursing home physicians and staff in seven states found that reducing antipsychotics is more time and resource-intensive than relying on medication, because it requires a person-centered approach. However, respondents supported reductions in antipsychotic use, and indicated that with sufficient staffing, effective communications, and training, they could create or implement individualized treatments. Their positive attitudes suggest that the National Partnership has been a catalyst in reducing antipsychotic medications, and their perspectives can inform further research, policy and practice in nursing homes toward achieving quality dementia care.
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Dhuny S, Foley T, Jennings A. General practitioners' knowledge of and attitudes towards prescribing psychoactive drugs in dementia care: a cross-sectional questionnaire study. Ir J Med Sci 2020; 190:667-675. [PMID: 32897448 PMCID: PMC7477732 DOI: 10.1007/s11845-020-02356-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/31/2020] [Indexed: 11/25/2022]
Abstract
Background Despite their adverse effects, antipsychotics are frequently prescribed to manage behavioural and psychological symptoms of dementia (BPSD). At present, we do not have a good understanding of general practitioners’ (GPs) current management of BPSD. Aims To explore the knowledge, attitudes, and opinions of GPs regarding the prescribing of psychoactive drugs in managing BPSD. Methods This was a descriptive cross-sectional study. A questionnaire was adapted from a previous study and piloted with three GPs and was posted to a census sample of all GPs working in counties Cork and Kerry, Ireland. We collected and analysed both quantitative and qualitative data. Results Of the 456 eligible GPs who received the questionnaire, 168 GPs returned completed questionnaires (response rate 36.8%). All respondents (100%, 168/168) believed that antipsychotics did not benefit all patients with BPSD. The majority of GPs (69%, 116/168) routinely recommended non-pharmacological interventions before medication to manage BPSD. Most GPs (60.7%, 102/168) welcomed more training and experience to improve their management of BPSD. The qualitative comments provided by GPs described a pressure to prescribe from nursing home staff. GPs highlighted that the management of BPSD is difficult in daily practice and felt that antipsychotics still have a role to play. Conclusions This study identified several factors influencing the prescription of antipsychotics for patients with BPSD as well as the prescribing dilemmas faced by GPs in their daily practice. These findings can be used to guide future interventions aimed at reducing inappropriate prescribing in dementia care. Electronic supplementary material The online version of this article (10.1007/s11845-020-02356-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sheefah Dhuny
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland.
| | - Tony Foley
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland
| | - Aisling Jennings
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland
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Crystal S, Jarrín OF, Rosenthal M, Hermida R, Angell B. National Partnership to Improve Dementia Care in Nursing Homes Campaign: State and Facility Strategies, Impact, and Antipsychotic Reduction Outcomes. Innov Aging 2020; 4:igaa018. [PMID: 32699827 PMCID: PMC7365953 DOI: 10.1093/geroni/igaa018] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Indexed: 12/14/2022] Open
Abstract
Background and Objectives Antipsychotic medications have been widely used in nursing homes to manage behavioral and psychological symptoms of dementia, despite significantly increased mortality risk. Use grew rapidly during the 2000s, reaching 23.9% of residents by 2011. A national campaign for safer dementia care in U.S. nursing homes was launched in 2012, with public reporting of quality measures, increased regulatory scrutiny, and accompanying state and facility initiatives. By the second quarter of 2019, use had declined by 40.1% to 14.3%. We assessed the impact of state and facility initiatives during the Campaign aimed at encouraging more-judicious prescribing of antipsychotic medications. Research Design and Methods Our mixed-methods strategy integrated administrative and clinical data analyses with state and facility case studies. Results Results suggest that substantial change in prescribing is achievable through sustained, data-informed quality improvement initiatives integrating educational and regulatory interventions, supported by public quality reporting. Adequate staffing, particularly of registered nurses, is key to support individualized management of symptoms through nonpharmacological strategies. Case study results suggest that state and facility initiatives during the campaign achieved considerable buy-in for the goal of more conservative prescribing, through a social process of normalization. Reporting and reduction of antipsychotic use was not followed by increases in sedative-hypnotic medication use. Rather, sedative-hypnotic use declined in tandem with antipsychotic reduction, suggesting that increased attention to prescribing patterns led to more cautious use of other risky psychotropic medications. Discussion and Implications Quality improvement initiatives to change entrenched but problematic clinical practices face many barriers to success, including provider-level inertia; perceptions that alternatives are not available; and family and staff resistance. Nevertheless, systemic change is possible through concerted, collaborative efforts that touch prescribing practices at multiple points; integrate educational and regulatory influences; activate local and state champions for improvement; foster reputational influences through public reporting and benchmarking; and support a social process of normalization of preferred care processes as a best practice that is in the interest of patients.
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Affiliation(s)
- Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick.,School of Social Work, Rutgers, The State University of New Jersey, New Brunswick
| | - Olga F Jarrín
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick.,School of Nursing, Rutgers, The State University of New Jersey, Newark
| | - Marsha Rosenthal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick
| | - Richard Hermida
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick
| | - Beth Angell
- School of Social Work, Virginia Commonwealth University, Richmond
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Educating Nursing Home Staff in Dementia Sensitive Communication: Impact on Antipsychotic Medication Use. J Am Med Dir Assoc 2019; 19:1129-1132. [PMID: 30471803 DOI: 10.1016/j.jamda.2018.09.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES An educational program to enhance communication in nursing home dementia care increased person-centered communication by staff and resulted in reduced resident behavioral symptoms measured as resistiveness to care. The purpose of this analysis was to evaluate effects on resident antipsychotic medication use in participating nursing homes. The National Partnership to Improve Dementia Care set a goal of reducing antipsychotic medications in nursing homes by 15% during the study period. DESIGN A post hoc analysis of Nursing Home Compare data was used to evaluate change in antipsychotic medication rates in nursing homes receiving the communication education versus the corresponding statewide average change. SETTING AND PARTICIPANTS Eleven nursing homes participated in a cluster-randomized controlled trial from 2011 to 2013 in one Midwestern state. MEASURES Antipsychotic medication rates were abstracted from Nursing Home Compare data sets. Antipsychotic medication rates were compared for each participating nursing home for the 2 quarters before and the 2 quarters after the communication intervention. To control for other factors supporting reduction in antipsychotic use, changes in the participating nursing homes were compared to the state average change for the corresponding quarters using a 1-sample t test. RESULTS Antipsychotic medication use decreased on average by 4.88 percentage points (22.9%) in participating nursing homes compared to the state average decrease of 0.68 percentage points (2.7%) during the same period (P = .06). CONCLUSIONS A clinically meaningful reduction in antipsychotic medication usage occurred in the nursing homes that received communication education. Measurable changes in communication and behavioral symptoms were reflected in reductions in antipsychotic medication usage. Improving staff communication has the potential to reduce inappropriate antipsychotic medication use in long-term care.
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24
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Kirkham J, Maxwell C, Velkers C, Leung R, Moffat K, Seitz D. Optimizing Prescribing of Antipsychotics in Long-Term Care (OPAL): A Stepped-Wedge Trial. J Am Med Dir Assoc 2019; 21:381-387.e3. [PMID: 31558380 DOI: 10.1016/j.jamda.2019.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/22/2019] [Accepted: 07/27/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Inappropriate antipsychotic prescribing is a key quality indicator by which clinical outcomes might be monitored and improved in long-term care (LTC), but limited evidence exists on the most effective strategies for reducing inappropriate antipsychotic use. OBJECTIVES The objective of the study was to evaluate a multicomponent approach to reduce inappropriate prescribing of antipsychotics in LTC. DESIGN A prospective, stepped-wedge study design was used to evaluate the effect of the intervention. SETTINGS AND PARTICIPANTS Interdisciplinary staff at 10 Canadian LTC facilities. METHODS The intervention consisted of an educational in-service, provision of evidence-based tools to assess and monitor neuropsychiatric symptoms (NPS) in dementia, and monthly interprofessional team meetings. The primary outcome was the proportion of residents receiving an antipsychotic without a diagnosis of psychosis using a standardized antipsychotic quality indicator. RESULTS The weighted mean change in inappropriate antipsychotic prescribing rate from baseline to 12-month follow-up was -4.6% [standard deviation (SD) = 2.8%, P < .0001], representing a 16.1% (SD = 17.0) relative reduction. After adjusting for site, the odds ratio for the inappropriate antipsychotic prescribing quality indicator at 12 months compared to baseline was 0.73 (95% confidence interval = 0.48-0.94; chi-square = 6.59; P = .01). There were no significant changes in related quality indicators, including falls, restraint use, or behavioral symptoms. CONCLUSIONS AND IMPLICATIONS This multicomponent intervention was effective in reducing inappropriate antipsychotic prescribing in LTC without adversely affecting other domains related to quality of care, and offers a practical means by which to improve the care of older adults with dementia in LTC.
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Affiliation(s)
- Julia Kirkham
- Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada.
| | - Colleen Maxwell
- School of Pharmacy and Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Clive Velkers
- Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Roxanne Leung
- Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Kathryn Moffat
- Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Dallas Seitz
- Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada
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25
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Kalisch Ellett LM, Moffat AK, Gadzhanova S, Pratt NL, Apajee J, Woodward M, Roughead EE. Reduction in Use of Risperidone for Dementia in Australia Following Changed Guidelines. PHARMACY 2019; 7:pharmacy7030100. [PMID: 31336574 PMCID: PMC6789876 DOI: 10.3390/pharmacy7030100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/01/2019] [Accepted: 07/15/2019] [Indexed: 12/30/2022] Open
Abstract
Background: Risperidone is the only antipsychotic approved in Australia for the management of the behavioural and psychological symptoms of dementia (BPSD). In June 2015, the Australian Government Therapeutic Goods Administration (TGA) amended the indication to restrict use in BPSD to patients with Alzheimer's dementia for a maximum twelve-week duration. We aimed to determine whether the rate and duration of risperidone use for BPSD decreased following the regulatory changes. Methods: we conducted a study using the Australian Government Department of Veterans' Affairs administrative claims data and Pharmaceutical Benefits Scheme (PBS) 10% sample data. We included people aged 65 years or older and compared the rate and duration of risperidone use before and after the TGA labelling changes. Results: There was a sustained decrease in the trend of risperidone use for BPSD following the TGA labelling changes, with a monthly decrease of 1.7% in the aged care population, 0.5% in the community living population and 1.5% in the general older Australian population. Overall, in the 24 months post the TGA changes the reduction in the rate of use of risperidone ranged from 20% to 28% lower than compared to what the rate would have been without the TGA changes. The median duration of use of risperidone in aged-care residents decreased from 338 days in the year prior to the TGA labelling changes, to 240 days per person in the year after the changes. Conclusion: The TGA labelling changes were associated with a significant reduction in the rate of use of risperidone for BPSD in veterans living in both the aged care and community settings, and in the general older Australian population. The labelling changes were also associated with a reduced duration of risperidone use in aged care residents, although for most people the duration of use still exceeded the recommended 12-week maximum duration.
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Affiliation(s)
- Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia.
| | - Anna K Moffat
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
| | - Svetla Gadzhanova
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
| | - Nicole L Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
| | - Jemisha Apajee
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
| | - Michael Woodward
- Austin Health, GPO Box 5444, Heidelberg West, Victoria 3081, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
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26
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Perceptions of Antibiotic Therapy Among Nursing Home Residents: Perspectives of Caregivers and Residents in a Mixed Exploratory Study. Antibiotics (Basel) 2019; 8:antibiotics8020066. [PMID: 31137842 PMCID: PMC6627220 DOI: 10.3390/antibiotics8020066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/09/2019] [Accepted: 05/23/2019] [Indexed: 12/17/2022] Open
Abstract
Antimicrobial resistance is a major public health threat worldwide. Some authors have suggested that end-users of nursing homes have an influence on antibiotic prescribing. The objective of this study is to describe the views of end-users and professionals on residents' behavior towards antibiotic therapy in terms of knowledge, beliefs, and attitudes towards this drug class and its prescribing process. This is a concurrent mixed methodology study using questionnaires and semi-directive individual interviews with nursing homes residents, nurses, and doctors practicing in these facilities. The questionnaires analyzed were collected from 35 residents (24.3%) and 109 nurses (75.7%). The qualitative interview involved 26 of total participants that agreed to be interviewed. We noticed misconceptions being held by the residents regarding the antibiotic resistance phenomenon. Additionally, nurses were not considered as a source of information about antibiotics. Nurses and residents had conflicting opinions about residents requesting antibiotics, and the findings depict a stereotypical view of the nurse profession as a reflection of a cognitive representation. The authors conclude that, despite many campaigns, further efforts are needed to tackle antimicrobial resistance. Initiatives could include raising awareness about antimicrobial resistance, clarifying the role of nurses, and communicating well with residents about their needs in nursing homes.
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27
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Hall AM, Scurrey SR, Pike AE, Albury C, Richmond HL, Matthews J, Toomey E, Hayden JA, Etchegary H. Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework. Implement Sci 2019; 14:49. [PMID: 31064375 PMCID: PMC6505266 DOI: 10.1186/s13012-019-0884-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 03/27/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Adoption of low back pain guidelines is a well-documented problem. Information to guide the development of behaviour change interventions is needed. The review is the first to synthesise the evidence regarding physicians' barriers to providing evidence-based care for LBP using the Theoretical Domains Framework (TDF). Using the TDF allowed us to map specific physician-reported barriers to individual guideline recommendations. Therefore, the results can provide direction to future interventions to increase physician compliance with evidence-based care for LBP. METHODS We searched the literature for qualitative studies from inception to July 2018. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study characteristics, reporting quality, and methodological rigour. Guided by a TDF coding manual, two reviewers independently coded the individual study themes using NVivo. After coding, we assessed confidence in the findings using the GRADE-CERQual approach. RESULTS Fourteen studies (n = 318 physicians) from 9 countries reported barriers to adopting one of the 5 guideline-recommended behaviours regarding in-clinic diagnostic assessments (9 studies, n = 198), advice on activity (7 studies, n = 194), medication prescription (2 studies, n = 39), imaging referrals (11 studies, n = 270), and treatment/specialist referrals (8 studies, n = 193). Imaging behaviour is influenced by (1) social influence-from patients requesting an image or wanting a diagnosis (n = 252, 9 studies), (2) beliefs about consequence-physicians believe that providing a scan will reassure patients (n = 175, 6 studies), and (3) environmental context and resources-physicians report a lack of time to have a conversation with patients about diagnosis and why a scan is not needed (n = 179, 6 studies). Referrals to conservative care is influenced by environmental context and resources-long wait-times or a complete lack of access to adjunct services prevented physicians from referring to these services (n = 82, 5 studies). CONCLUSIONS Physicians face numerous barriers to providing evidence-based LBP care which we have mapped onto 7 TDF domains. Two to five TDF domains are involved in determining physician behaviour, confirming the complexity of this problem. This is important as interventions often target a single domain where multiple domains are involved. Interventions designed to address all the domains involved while considering context-specific factors may prove most successful in increasing guideline adoption. REGISTRATION PROSPERO 2017, CRD42017070703.
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Affiliation(s)
- Amanda M Hall
- Primary Healthcare Research Unit (PHRU), Faculty of Medicine, Memorial University, Room 417
- Janeway Hostel, Health Sciences Centre, 300 Prince Philip Parkway, St. John's, NL, A1B 3V6, Canada.
| | - Samantha R Scurrey
- Primary Healthcare Research Unit (PHRU), Faculty of Medicine, Memorial University, Room 417
- Janeway Hostel, Health Sciences Centre, 300 Prince Philip Parkway, St. John's, NL, A1B 3V6, Canada
| | - Andrea E Pike
- Primary Healthcare Research Unit (PHRU), Faculty of Medicine, Memorial University, Room 417
- Janeway Hostel, Health Sciences Centre, 300 Prince Philip Parkway, St. John's, NL, A1B 3V6, Canada
| | - Charlotte Albury
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Helen L Richmond
- Centre for Rehabilitation Research in Oxford, University of Oxford, Oxford, UK
| | - James Matthews
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Elaine Toomey
- School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Jill A Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Holly Etchegary
- Clinical Epidemiology, Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
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28
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Laffon de Mazières C, Lapeyre-Mestre M, Vellas B, de Souto Barreto P, Rolland Y. Impact of a geriatric intervention conducted in nursing homes on inappropriate prescriptions of antipsychotics. Eur Geriatr Med 2019; 10:285-293. [PMID: 34652759 DOI: 10.1007/s41999-018-00155-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 12/17/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To study the effect of a quality assurance approach in a nursing home, with or without the intervention of a geriatrician, on the potentially inappropriate prescription of antipsychotics (PIPA) at 18 months; and to identify the factors associated with PIPA after 18 months of intervention (T18). METHODS We used data from a multicentre individually tailored controlled trial (IQUARE study). The study population comprised residents included in the IQUARE study with at least one potentially inappropriate prescription of antipsychotics at baseline (T0) who were still in nursing home at T18 (n = 636; nursing homes = 175). The control group received individual feedback from the quality assurance audit performed at baseline. The intervention group also had at least 5 collaborative work meetings with a geriatrician over an 18-month period. We used a multilevel logistic regression model. RESULTS The rates of inappropriate antipsychotic drug prescribing were 66.5% and 45.2% at T0 and T18, respectively. This decrease in the rate of PIPA is significant (p < 0.001). A significant decrease was found within each group: in the intervention arm (68.1% at T0 vs. 44.6% at T18; p < 0.001) and in the control arm (65.2% at T0 vs. 45.6% at T18; p < 0.001). Multivariate analysis did not highlight any statistically significant association between living in a nursing home having received an intervention and PIPA at T18. CONCLUSIONS Collaborative work meetings with a geriatrician does not provide significant added value to a global quality assurance approach towards PIPA. Individual feedback to each nursing home appears to have a substantial impact on decreasing PIPA.
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Affiliation(s)
- Clarisse Laffon de Mazières
- Department of Geriatric Medicine, Toulouse University Hospital (CHU de Toulouse), Gérontopôle, Toulouse, France. .,Inserm UMR 1027, 37 Allées Jules Guesde, Toulouse, France.
| | - Maryse Lapeyre-Mestre
- Inserm UMR 1027, 37 Allées Jules Guesde, Toulouse, France.,Department of Medical and Clinical Pharmacology, CIc 1436, CHU de Toulouse, 37 Allées Jules Guesde, Toulouse, France
| | - Bruno Vellas
- Department of Geriatric Medicine, Toulouse University Hospital (CHU de Toulouse), Gérontopôle, Toulouse, France.,Inserm UMR 1027, 37 Allées Jules Guesde, Toulouse, France
| | - Philipe de Souto Barreto
- Department of Geriatric Medicine, Toulouse University Hospital (CHU de Toulouse), Gérontopôle, Toulouse, France.,Inserm UMR 1027, 37 Allées Jules Guesde, Toulouse, France
| | - Yves Rolland
- Department of Geriatric Medicine, Toulouse University Hospital (CHU de Toulouse), Gérontopôle, Toulouse, France.,Inserm UMR 1027, 37 Allées Jules Guesde, Toulouse, France
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29
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Jennings AA, Guerin N, Foley T. Development of a tool for monitoring the prescribing of antipsychotic medications to people with dementia in general practice: a modified eDelphi consensus study. Clin Interv Aging 2018; 13:2107-2117. [PMID: 30425465 PMCID: PMC6203170 DOI: 10.2147/cia.s178216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Despite their adverse effects, antipsychotics are frequently used to manage behavioral and psychological symptoms of dementia. Regular monitoring of antipsychotic prescribing has been shown to improve the appropriateness of prescribing. However, there is currently no consensus on what the components of such a monitoring tool would be. Aim The aim of this study was to use an expert consensus process to identify the key components of an antipsychotic repeat prescribing tool for use with people with dementia in a general practice setting. Methods A modified eDelphi technique was employed. We invited multidisciplinary experts in antipsychotic prescribing to people with dementia to participate. These experts included general practitioners (GPs), geriatricians and old age psychiatrists. The list of statements for round 1 was developed through a review of existing monitoring tools and international best practice guidelines. In the second round of the Delphi, any statement that had not reached consensus in the first round was presented for re-rating, with personalized feedback on the group and the individual’s response to the specific statement. The final round consisted of a face-to-face expert meeting to resolve any uncertainties from round 2. Results A total of 23 items were rated over two eDelphi rounds and one face-to-face consensus meeting to yield a total of 18 endorsed items and five rejected items. The endorsed statements informed the development of a structured, repeat prescribing tool for monitoring antipsychotics in people with dementia in primary care. Conclusion The development of repeat prescribing tool provides GPs with practical advice that is lacking in current guidelines and will help to support GPs by providing a structured format to use when reviewing antipsychotic prescriptions for people with dementia, ultimately improving patient care. The feasibility and acceptability of the tool now need to be evaluated in clinical practice.
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Affiliation(s)
| | - Naoihse Guerin
- Department of General Practice, University College Cork, Cork, Ireland,
| | - Tony Foley
- Department of General Practice, University College Cork, Cork, Ireland,
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30
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Walsh KA, Sinnott C, Fleming A, Mc Sharry J, Byrne S, Browne J, Timmons S. Exploring Antipsychotic Prescribing Behaviors for Nursing Home Residents With Dementia: A Qualitative Study. J Am Med Dir Assoc 2018; 19:948-958.e12. [PMID: 30241987 DOI: 10.1016/j.jamda.2018.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/03/2018] [Accepted: 07/07/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Caution is advised when prescribing antipsychotics to people with dementia. This study explored the determinants of appropriate, evidence-based antipsychotic prescribing behaviors for nursing home residents with dementia, with a view to informing future quality improvement efforts and behavior change interventions. DESIGN Semistructured qualitative interviews based on the Theoretical Domains Framework (TDF). SETTING AND PARTICIPANTS A purposive sample of 27 participants from 4 nursing homes, involved in the care of nursing home residents with dementia (8 nurses, 5 general practitioners, 5 healthcare assistants, 3 family members, 2 pharmacists, 2 consultant geriatricians, and 2 consultant psychiatrists of old age) in a Southern region of Ireland. MEASURES Using framework analysis, the predominant TDF domains and determinants influencing these behaviors were identified, and explanatory themes developed. RESULTS Nine predominant TDF domains were identified as influencing appropriate antipsychotic prescribing behaviors. Participants' effort to achieve "a fine balance" between the risks and benefits of antipsychotics was identified as the cross-cutting theme that underpinned many of the behavioral determinants. On one hand, neither healthcare workers nor family members wanted to see residents over-sedated and without a quality of life. Conversely, the reality of needing to protect staff, family members, and residents from potentially dangerous behavioral symptoms, in a resource-poor environment, was emphasized. The implementation of best-practice guidelines was illustrated through 3 explanatory themes ("human suffering"; "the interface between resident and nursing home"; and "power and knowledge: complex stakeholder dynamics"), which conceptualize how different nursing homes strike this "fine balance." CONCLUSIONS Implementing evidence-based antipsychotic prescribing practices for nursing home residents with dementia remains a significant challenge. Greater policy and institutional support is required to help stakeholders strike that "fine balance" and ultimately make better prescribing decisions. This study has generated a deeper understanding of this complex issue and will inform the development of an evidence-based intervention.
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Affiliation(s)
- Kieran A Walsh
- Center for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland; Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland; School of Public Health, University College Cork, Cork, Ireland.
| | - Carol Sinnott
- The Healthcare Improvement Studies (THIS) Institute, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Aoife Fleming
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland; Pharmacy Department, Mercy University Hospital, Cork, Ireland
| | - Jenny Mc Sharry
- Health Behavior Change Research Group, School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Suzanne Timmons
- Center for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
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Bartley MM, Suarez L, Shafi RMA, Baruth JM, Benarroch AJM, Lapid MI. Dementia Care at End of Life: Current Approaches. Curr Psychiatry Rep 2018; 20:50. [PMID: 29936639 DOI: 10.1007/s11920-018-0915-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Dementia is a progressive and life-limiting condition that can be described in three stages: early, middle, and late. This article reviews current literature on late-stage dementia. RECENT FINDINGS Survival times may vary across dementia subtypes. Yet, the overall trajectory is characterized by progressive decline until death. Ideally, as people with dementia approach the end of life, care should focus on comfort, dignity, and quality of life. However, barriers prevent optimal end-of-life care in the final stages of dementia. Improved and earlier advanced care planning for persons with dementia and their caregivers can help delineate goals of care and prepare for the inevitable complications of end-stage dementia. This allows for timely access to palliative and hospice care, which ultimately improves dementia end-of-life care.
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Affiliation(s)
| | - Laura Suarez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Reem M A Shafi
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Joshua M Baruth
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Amanda J M Benarroch
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Maria I Lapid
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA. .,Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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32
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Jennings AA, Foley T, Walsh KA, Coffey A, Browne JP, Bradley CP. General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed-methods systematic review. Int J Geriatr Psychiatry 2018; 33:1163-1176. [PMID: 29900592 PMCID: PMC6099359 DOI: 10.1002/gps.4918] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 04/03/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To synthesise the existing published literature on general practitioners (GP)'s knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia (BPSD) with a view to informing future interventions. METHODS We conducted a systematic review and synthesis of quantitative and qualitative studies that explored GPs' experiences of managing BPSD (PROSPERO protocol registration CRD42017054916). Seven electronic databases were searched from inception to October 2017. Each stage of the review process involved at least 2 authors working independently. The meta-ethnographic approach was used to synthesise the findings of the included studies while preserving the context of the primary data. The Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to assess the confidence in our individual review findings. RESULTS Of the 1638 articles identified, 76 full texts were reviewed and 11 were included. Three main concepts specific to GPs' experiences of managing BPSD emerged: unmet primary care resource needs, justification of antipsychotic prescribing, and the pivotal role of families. A "line of argument" was drawn, which described how in the context of resource limitations a therapeutic void was created. This resulted in GPs being over reliant on antipsychotics and family caregivers. These factors appeared to culminate in a reactive response to BPSD whereby behaviours and symptoms could escalate until a crisis point was reached. CONCLUSION This systematic review offers new insights into GPs' perspectives on the management of BPSD and will help to inform the design and development of interventions to support GPs managing BPSD.
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Affiliation(s)
- Aisling A. Jennings
- Department of General Practice, School of MedicineUniversity College CorkCorkIreland
| | - Tony Foley
- Department of General Practice, School of MedicineUniversity College CorkCorkIreland
| | - Kieran A. Walsh
- School of Public HealthUniversity College CorkCorkIreland
- Pharmaceutical Care Research Group, School of PharmacyUniversity College CorkCorkIreland
- Centre for Gerontology and Rehabilitation, School of MedicineUniversity College CorkCorkIreland
| | - Alice Coffey
- Department of Nursing and MidwiferyUniversity of LimerickLimerickIreland
| | - John P. Browne
- School of Public HealthUniversity College CorkCorkIreland
| | - Colin P. Bradley
- Department of General Practice, School of MedicineUniversity College CorkCorkIreland
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Jennings AA, Foley T, Walsh KA, Coffey A, Browne JP, Bradley CP. General practitioners' knowledge, attitudes and experiences of managing behavioural and psychological symptoms of dementia: protocol of a mixed methods systematic review and meta-ethnography. Syst Rev 2018; 7:62. [PMID: 29685175 PMCID: PMC5913890 DOI: 10.1186/s13643-018-0732-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 04/13/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In the context of rising dementia prevalence, the workload of general practitioners (GPs) in dementia care is set to increase. However, there are many aspects of dementia care that GPs find challenging. Behavioural and psychological symptoms of dementia (BPSD) affect the majority of people with dementia and is an aspect of dementia care that GPs find particularly difficult to manage. The aim of this mixed methods systematic review is to undertake a synthesis of qualitative and quantitative studies on GPs' knowledge, attitudes and experiences of managing BPSD. METHODS Seven electronic bibliographic databases will be searched from inception to present. All qualitative or quantitative studies that explore the knowledge, attitude or experiences of GPs towards the management of BPSD in community and/or residential settings will be eligible for inclusion. A meta-ethnography will be conducted to synthesise included studies. Primary outcome measures will include GPs' experiences of managing BPSD, GPs' knowledge of BPSD and their attitude to different approaches to the management of BPSD, in particular their attitude to non-pharmacological approaches. All included papers will be independently assessed for methodological validity by two reviewers using the following tools: the Joanna Briggs Institute checklist for qualitative research, the Effective Public Health Practice Project (EPHPP) tool for intervention studies and the National Institute of Health (NIH) quality assessment tool for observational and analytical cross-sectional studies. As there is no agreed quality assessment tool for descriptive cross-sectional studies, an original tool will be developed. Two independent reviewers will apply the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) tool to the review findings. The results will be reported in line with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. DISCUSSION This study will be the first systematic review that synthesises the existing literature of GPs' knowledge, attitudes and experiences of managing BPSD in community and residential care. This review will improve our understanding of GPs' perspectives on the management of BPSD, and the results will be used to inform the development of an intervention to improve the management of BPSD in general practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017054916 .
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Affiliation(s)
| | - Tony Foley
- Department of General Practice, University College Cork, Cork, Ireland
| | - Kieran A. Walsh
- School of Public Health, University College Cork, Cork, Ireland
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | - Alice Coffey
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - John P. Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Colin P. Bradley
- Department of General Practice, University College Cork, Cork, Ireland
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Morley JE. A Decade of JAMDA. J Am Med Dir Assoc 2017; 18:993-997. [PMID: 29169742 DOI: 10.1016/j.jamda.2017.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
Affiliation(s)
- John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St Louis, MO.
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